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 Table of Contents  
IDEAS AND INNOVATIONS
Year : 2014  |  Volume : 1  |  Issue : 2  |  Page : 109-111

A modified approach for submucous cleft palate surgery: Minimal access palatoplasty


Department of Plastic and Reconstructive Surgery, Vikram Hospital, Mysore, Karnataka, India

Date of Web Publication2-Aug-2014

Correspondence Address:
Dr. Satish Hassan Visweshwar
Vikram Hospital, 892, 1st Cross, I Block, Ramakrishna Nagar, Mysore - 570 023, Karnataka
India
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Source of Support: These procedures were subsidised by Smile Train Inc., New York., Conflict of Interest: None


DOI: 10.4103/2348-2125.137904

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  Abstract 

A Submucous Cleft of the Palate presents a surgical challenge to improve function in an apparently normal area. Surgery itself should not add to the morbidity. Traditional approaches leave extensive or significant scarring and sometimes fistulae. A technique, termed as Minimal Access Palatoplasty (MAP) was designed to avoid these sequelae and facilitate surgery. 28 consecutive patients with submucous clefts were operated using this technique by a single surgeon over a period of 4 years. Patients were reviewed for surgical outcome. Follow up ranged from 4 weeks to 3 years. None of the patients had a fistula. Results are presented. This technique takes less time, is easy for even a novice and can be used in combination with Levator muscle dissection or Furlows technique as desired.

Keywords: Minimal access, new approach, submucous cleft palate


How to cite this article:
Visweshwar SH. A modified approach for submucous cleft palate surgery: Minimal access palatoplasty. J Cleft Lip Palate Craniofac Anomal 2014;1:109-11

How to cite this URL:
Visweshwar SH. A modified approach for submucous cleft palate surgery: Minimal access palatoplasty. J Cleft Lip Palate Craniofac Anomal [serial online] 2014 [cited 2019 Aug 26];1:109-11. Available from: http://www.jclpca.org/text.asp?2014/1/2/109/137904


  Introduction Top


Submucous cleft of the palate is usually identified when the child is older. Surgery is generally advised after speech evaluation and assessment. Surgically the separation of the thinned nasal layer and oral layer is time consuming and difficult. It is also often necessary to excise a central strip of the thinned oral and nasal layer to enable suturing. The possibility of fistula formation and/or scarring leading to a suboptimally mobile palate exists. In one series two patients (out of 48) had a palatal fistula. [1] The author has seen two patients who have been operated earlier, presenting with fistulae. A new approach termed as minimal access palatoplasty (MAP) has been designed to enhance ease of surgery, reduce scarring, and enable good functional results. It is technically easy and reduces operative time.


  Subjects and Methods Top


Over a 4-year period from October 2009 to June 2013, 28 cases of submucous cleft palate were operated by a single surgeon. Follow-up ranged from 4 weeks to 3 years.

Surgical technique

The marking starts in the midline at the incisive foramen (where palpable bone is present). The incision follows the midline and proceeds posteriorly until the point where the cleft in the posterior nasal spine is felt [Figure 1]. At this point, an ellipse is marked, skirting just beyond the bony cleft and running on the bone. The ellipse ends 1-2 cm behind (depending on the size of the palate) and continues in the midline. A Z-plasty is marked on the oral layer.
Figure 1: The marking of the incision on the palate

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The anterior markings allow an incision with some firmness as it lies on bone. In the posterior part (soft palate), the knife is used softly to make a shallow incision. The mucoperiosteal flaps are raised in a lateral direction. The central island, consisting of the oral mucosal island attached to an inviolate nasal layer, is left undisturbed. Using the plane identified at the posterior palatine shelf becomes the guide and using blunt dissection and due care, it is possible to raise the oral layer off the midline in the soft palate. The nasal layer is thus left intact. The uvula is then split. The options of performing a Furlows' procedure or a radical muscle dissection are available now.

In this group, the access was sufficient in all cases [Figure 2]. In this series, all patients underwent a microscope assisted levator muscle sling creation with an oral layer Z-plasty. At the end of the procedure, closure was easy. Stitches were taken for approximation as there was no tension and no fear of fistula. The central island was sometimes partly overlapped by the closure in which case lose tagging sutures were taken to eliminate over hanging.
Figure 2: The access provided by this incision is adequate for levator muscle dissection

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Postoperative care was routine.


  Results Top


The average age of the patient was 11.8 years. The male to female distribution was 1.55:1.The average operative time for the procedure was 59 min. Average hospital stay was 1.7 days. None of the patients developed any serious adverse events.

The healing was uneventful in 26 of 28 patients [Figure 3] at 4 weeks. Two patients showed evidence of congestion of the central island, [Figure 4], which settled without intervention. No patient had developed a fistula during the fourth week follow-up. Of these, 15 patients were seen on further follow-up and referred for speech therapy. Outcome evaluation is in progress.
Figure 3: The appearance of the palate after healing

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Figure 4: The central island is congested. It survived fully

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The need to reduce scarring in a highly mobile structure places the burden on the surgeon to achieve more with less. Hwang has described a procedure leaving the nasal layer intact, but makes a W shaped incision on the oral layer to lengthen the palate. The oral layer incision is extensive and also encroaches the retromolar area. [2]

Minimal access palatoplasty was designed because a midline incision of the oral layer alone is sufficient to provide access to the levator sling. Leaving the nasal layer intact means less surgery and less scarring.

In sub mucous clefts, the oral and nasal layer are very thin in the midline and can tear with gentle traction also. They do appear strong enough to sustain the normal functional forces applied on them. The chance of a tear is highest at the junctional area. By skirting the treacherous area of the posterior nasal spine, the need for a cautious dissection was obviated. MAP addresses these problems effectively.

In this procedure, a Z-plasty was incorporated into the oral layer to avoid a straight line scar and to avoid midline scar adhesion. The intact and elastic nasal layer retains its ability to stretch.

Since this is only an altered access, the functional results of levator retroposition are not adversely affected at all. On the other hand with lesser scar, the outcome may improve.

If a repair by Furlow's technique repair is planned, this approach saves time in splitting the thinned midline into oral and nasal layers, obviates the need for raising the anterior mucoperisoteal flaps for purpose of closure at the junctional area.


  Conclusion Top


Some technical challenges of operating on a submucous cleft palate have been addressed by the MAP technique. It enables easier and faster access to the critical area (levator muscle) and leaves fewer scars behind. Collateral advantages include faster postoperative recovery and elimination of the chance of fistula formation.

This access technique is recommended for use in submucous cleft palates operated by levator retroposition or by Furlow's technique.

 
  References Top

1.Sie KC, Tampakopoulou DA, Sorom J, Gruss JS, Eblen LE. Results with Furlow palatoplasty in management of velopharyngeal insufficiency. Plast Reconstr Surg 2001;108:17-25.  Back to cited text no. 1
[PUBMED]    
2.Hwang K. Repair of a submucous cleft palate by W-pushback and levator repositioning without incision to the nasal mucosa. J Craniofac Surg 2012;23:543-5.  Back to cited text no. 2
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Subjects and Methods
Results
Conclusion
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